- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $10,964.78
| Facility | | $2,238.72 | $3,090.30 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,691.53
| Professional | | $1,288.25 | $1,862.09 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,168.69 / $6,606.93
| Facility | | $2,290.87 | $4,168.69 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $16,218.10
| Facility | | $1,380.38 | $1,659.59 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,137.96 / $2,137.96
| Facility | | $891.25 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $2,951.21
| Professional | | $891.25 | $1,071.52 | $2,951.21 |